Health

Summary

C, parents of infant child (A) complained about the care and treatment that A had received from the board. C had raised concerns that A's Hickman line (a central line catheter inserted into one of the large blood vessels to allow permanent access for treatment) may be infected and had sought advice at hospital. A swab of the insertion site had taken place, however A had been discharged without further treatment. C complained that the board had failed to provide a reasonable standard of treatment to A during their admission.

C further complained that the following day at a home visit, nurses had proceeded to flush A's line (procedure required to ensure the line remains clear of blood and to prevent clotting) in spite of their concerns it might be infected and without the results of the swab testing. C asserted that as the line had been infected, A had received a septic shower (sudden systemic release of pathogens into the blood stream causing septic shock) resulting in A's sudden collapse.

In their response, the board said that as there had been no diagnosis of a line infection, A's line had been flushed in accordance with the board's Care and Maintenance policy (CVAD policy). However, reflecting on the complaint, the board acknowledged that had there been formal communication between services regarding A's swab testing the evening before, this may have influenced their decision-making to proceed with the flush. They said that as a result of the complaint, they would review and update their CVAD policy to incorporate a standard operating procedure (SOP) and checklist so as to improve information sharing between teams and in circumstances of swab testing, or concerns expressed by families, to ensure medical advice would be sought before proceeding.

We took independent advice from a paediatric nursing adviser and consultant paediatric adviser (dealing with the medical care of infants, children and young people). We found that although the board had correctly considered sepsis in their assessment of A during their hospital admission, they had failed to take appropriate account of the Sepsis 6 guidance, had failed to seek senior clinician advice, and further treatment should have been considered. We also found that in light of the known risk of sepsis associated with central line devices, and given the level of concern expressed by C, it would have been reasonable for the board to have delayed the flush of the line until after the swab results had become available. We also found that the board had failed to correctly follow their CVAD policy, specifically, nurses had not sought senior medical advice before proceeding, and the pro forma maintenance bundle had not been completed or recorded for the flushes of A's line.

C further complained that in investigating their complaint the board had failed to seek their account of events, and had only raised a DATIX (incident report) after they had made their complaint. We found that the board had failed to correctly manage the incident in accordance with their adverse event management policy and procedures which resulted in the family being denied the opportunity to present their evidence. We also found that there had been an unreasonable delay in reporting the DATIX, and the incident had not been escalated for consideration as a potential Serious Adverse Event Review.

We fully upheld all aspects of the complaint. However, in making our recommendations we took account of the board's proposed improvements to their existing CVAD policy which we considered adequate to address the failings identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take appropriate account of the Paediatric Sepsis 6 guidance in their assessment of A, failing to consider further treatment in line with the Paediatric Sepsis 6 treatment pathway, failing to seek senior clinician advice and failing to ensure formal communications with the ICCN team regarding A's attendance at the paediatric unit. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for failing to correctly follow their AEM policy and procedures by unreasonably delaying the DATIX and not escalating the incident for consideration as a potential SAER, for failing to carry out a reasonable investigation by not reporting events as a SAER or commissioning a SAER report and for failing to allow the family the opportunity to participate in the adverse review process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for proceeding to flush A's central venous line without the results of the swab testing, for failing to act on their concerns that the line may be infected, for failing to give fuller consideration to the known risk of sepsis associated with CVAD, for not adhering to the Hickman Patency Troubleshooting guide by failing to seek senior medical advice before proceeding with the flush and for not completing or recording the CVAD maintenance bundle for A's central venous line flushes. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should ensure relevant staff are reminded of the Scottish Patient Safety Programme Paediatric Sepsis 6 Guidance when considering treatment, specifically that there is a lower threshold for consideration of sepsis in patients with indwelling devices/lines, complex medical conditions and significant parental concern. The board should ensure that where there is a lower threshold for consideration of sepsis, senior clinician advice is sought.
• The board should ensure relevant staff are reminded of the board's adverse event management policy and procedures, and published best practice (HIS and IHI guidance) with regards to reporting, managing and analysing significant adverse events. The board must also ensure effective communication with families throughout the SAER process, and during any parallel complaint investigation.
• The board should ensure that when carrying out care and maintenance of central venous access devices in the community, that the CVAD maintenance bundle, including associated checklist, is completed and recorded in the clinical records.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C's parent (A) was admitted to Raigmore Hospital following a fall at home. A was diagnosed with delirium. After six weeks on the ward, A was discharged home with a package of care. A required readmission shortly after discharge and their condition deteriorated further. C complained that A's food and fluid intake were inadequately monitored during this period. C complained that the concerns they raised about their parent's physical and mental health were ignored.

C also complained about the hospital discharge process. C held Power of Attorney (POA) in respect of A and complained that the board did not have due regard to that. C complained that the board did not appropriately involve them in planning for A's discharge.

We took independent nursing advice. Although we were critical of aspects of the board's communication with A's family, we noted that on the whole, A's care and treatment were of a reasonable standard. We therefore, did not uphold the complaint. We were critical of the board for their delay in referring A to a dietitian, but we noted that the board had apologised for this and confirmed learning.

We considered that A's family could have been involved at an earlier stage when plans were being made for discharge. Overall, however, we noted that the discharge planning was reasonable, involving appropriate assessments and discussion with C. We did not uphold this complaint.

Summary

C complained about the board, regarding their treatment of a benign cyst. C complained that since being seen by the board they failed to take a proactive approach despite the pain and discomfort they were experiencing. C also complained that the board unreasonably prescribed antibiotics for an infection of the cyst which later transpired to not have been present.

On investigation, we took independent advice from a GP clinical adviser. We found that the board's treatment of C had been overall reasonable. On this basis, we did not uphold C's complaint.

Summary

C, the parent of A, complained about a delay in diagnosing A's thyroid cancer. A had an emergency admission to Dumfries and Galloway Royal Infirmary with acute tonsillitis and a lump was found on their neck. This lump was subsequently excised four months later, and cancer was diagnosed the following month. C complained that no prior indication had been given that cancer was suspected, and that the delay in diagnosing this led to unnecessary operations. They also complained about a subsequent delay in informing them about identified nodules on A's lung that were being monitored.

The board told us that they recognised that an earlier biopsy could have led directly to definitive surgery, without the need for further investigations or procedures and ultimately to a quicker resolution for A. They confirmed that they developed a new neck lump clinic as a result of this complaint. We took independent advice from a head and neck surgeon. We noted that A should have had an urgent needle biopsy at an earlier point in time. This would have led to an earlier diagnosis and less surgery. We noted that an excision should only have been considered if a diagnosis was not possible from the needle biopsy. Therefore, we upheld the complaint that there was an unreasonable delay in diagnosing A's cancer. We considered that the new neck lump clinic was the best way to avoid this happening again. While we were assured that the delay did not have an impact on A's prognosis, we noted that it will have added to the distress for A and the family.

In relation to C's concerns about not being advised sooner that cancer was suspected, we noted that cancer did not appear to have been considered earlier. We were, therefore, unable to conclude that there was a failure to communicate a suspicion of cancer. We noted that the board had already acknowledged that they did not make A aware of the lung nodules when they were identified. Therefore, on balance, we upheld the complaint that communication was unreasonable. The board had already apologised for this and they told us that they had revised their process to require clinicians to copy GP letters to patients.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the unreasonable delay in diagnosing A's cancer. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Neck lumps should be investigated with a needle biopsy in the first instance, and an excision should only be considered if a diagnosis is not possible from the needle biopsy. This should be undertaken urgently until cancer is excluded. This case should be discussed at the department's morbidity meeting and the findings of this investigation fed back to relevant staff in a supportive manner for reflection and learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received from the board. C said that they had been incorrectly diagnosed with Avoidant Personality Disorder (APD). C said that the board had failed to carry out a proper assessment of their presenting symptoms and incorrectly relied on historic information in reaching their diagnosis. They complained that the board's diagnosis had prevented them from accessing appropriate supports and treatment for other comorbidities.

According to NHS Inform, based on statistical information from England, personality disorders can affect one in 20 people and can be very difficult to live with.

In this case, we took independent advice from an adult psychiatry adviser. We considered that the board's diagnosis had been reasonable, however the possibility of a depressive disorder co-existing with this disorder's traits, and a physical disorder contributing to mood change, had not been adequately investigated. We also found that the board did not have an appropriate care pathway for APD, that staff had been unaware of it and that there was a lack of continuity in the board's procedures for requesting both internal and external opinions. Therefore, on balance we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a reasonable assessment of their symptoms. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The arrangements for requesting second opinions within the organisation, and external opinions, should be clarified.
• The care pathways for Personality Disorder should be clarified, and in particular the treatment options of Cluster C disorders such as Avoidant (Anxious) Personality Disorder.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about Scottish Ambulance Service's (SAS) failure to take appropriate action in response to patient A's symptoms. A had been ill for approximately two days with a high temperature, fever, followed by diarrhoea, trouble passing urine, extreme pain, breathlessness and struggling with mobility. When the SAS crew attended to A at home, an assessment was carried out and senior clinical advice was sought from the out-of-hours GP. It was decided that A did not require to be admitted at that time.

The following day A was admitted to hospital and later died from sepsis (blood infection). C complained that the SAS crew failed to recognise the signs of sepsis and to take the appropriate action in response to their symptoms.

As part of our investigation, we reviewed the relevant records and sought independent advice from a registered paramedic. We found that the SAS crew carried out an appropriate assessment of A's condition and that there was sufficient evidence that the possibility of sepsis was considered. We found that the SAS took the appropriate action in response to A's symptoms and we did not uphold the complaint.

Summary

C's child (A) had complex needs as a result of a brain injury sustained when they were four years old. Given A's care needs, they had an Anticipatory Care Plan (ACP) in place which was reviewed regularly.

A was admitted to a general ward at Ninewells Hospital with a high temperature and was subsequently moved to a high dependency unit. A died three days following admission.

C complained about the inappropriate use of Hi-Flo Nasal Cannula Oxygen (high-flow oxygen, a form of respiratory support) despite concerns raised at the time. C complained that incorrect decisions were taken with respect to A's care and treatment, including that clinicians did not have appropriate regard to the ACP that was in place.

In response to the complaint, the health board carried out a Mortality Review and shared its findings with C. The findings were that care was maximised in the High Dependency Unit as it was not felt A would survive admission to Paediatric Intensive Care Unit, and that this decision together with the decision not to intubate was made with C's input. The variation in care from the ACP was discussed with C and highlights plans are flexible.

C complained to our office that clinicians failed to follow the ACP, that they did not take their views into consideration and that A died of carbon monoxide poisoning as a result of the decisions made in relation to A's treatment and care.

We took independent advice from a consultant paediatrician. We found that there was good documentation evidencing that clinicians had discussed A's care with C, including decisions not to intubate A. We considered treatment with high-flow oxygen was reasonable in the circumstances. Whilst the ACP was not followed, and the board identified this, the ACP is not a legally binding document and the decisions to deviate from the ACP were reasonable in the circumstances. A's cause of death is consistent with the evidence within the medical records. We concluded that A's care and treatment was reasonable and did not uphold the complaint.

Summary

C attended the A&E at Ninewells Hospital with back pain and leg weakness, and was discharged with a diagnosis of suspected sciatica (back and leg pain caused by irritation or compression of the sciatic nerve). C had attended a neurology (the science of the nerves and the nervous system, especially of the diseases affecting them) out-patient clinic earlier that day regarding a separate matter, and the neurologist had noted a foot drop (a muscular weakness or paralysis that makes it difficult to lift the front part of the foot). C complained that the A&E failed to accurately assess them and refer them on to neurosurgery (surgery of the brain or other nerve tissue). C was assessed by neurosurgery four days later, following an urgent GP referral, and was diagnosed with disc prolapse (ruptured disc in the spine) and nerve compression (direct pressure on a nerve) requiring surgery that same day.

The board advised that, while the A&E doctor noted reduced power in C's left leg, they did not feel that foot drop was present and that they felt that sciatica was the most likely diagnosis. The board noted that the neurologist's observation that C had foot drop was not based on a physical examination, whereas the A&E doctor documented a physical examination. The board also noted that local neurosurgical referral guidelines state patients with back pain and sciatica with neurological deficit should be referred to physiotherapy prior to referral to neurosurgery. They concluded that C received appropriate care that was in keeping with relevant guidelines.

We took independent advice from a consultant in emergency medicine. We found that C's assessment and management in the A&E was reasonable and appropriate. We found that the mild weakness documented on assessment in the A&E was not in keeping with a foot drop and that it did not indicate that a neurosurgical referral was required at that time. The A&E discharge letter documented that C was advised to see their GP, and we noted that it was reasonable and in line with common practice for the A&E to ask the GP to follow-up rather than refer directly to physiotherapy. Therefore, we did not uphold the complaint.

Summary

C complained about the treatment provided to their late partner (A). A had reported a number of symptoms by telephone to their practice but they had not made arrangements to see them in person and C said that, as a result, they did not receive appropriate care and treatment. A reported symptoms over a period of time. However, A began to have seizures and tests revealed that A had lesions on their brain. C believed that the practice should have acted earlier and that A's condition could have been diagnosed sooner.

We took independent advice from an adviser who is an experienced GP. We found that the practice had provided A with appropriate care and treatment based on their reported symptoms. There was no evidence that A required an earlier face-to-face appointment or that red flag symptoms were missed.

We did not uphold the complaint.

Summary

C complained of a delay in diagnosing their late partner (A)'s cancer by medical staff in University Hospital Monklands. A was diagnosed with a rare cancer and died three weeks later. They had been unwell for around five months and had multiple hospital attendances and admissions. C complained that appropriate tests weren't carried out in a timely manner, and that A was misdiagnosed and treated for potential illnesses they did not have.

We took independent medical advice from a consultant in respiratory and general medicine. We found that A's case was complex and unusual and that it was reasonable to consider other diagnoses more likely than cancer, and to treat these accordingly while investigations continued. However, we found that reasonable action was not taken to manage the pleural effusions (fluid around the lung) that A initially presented with. Guidelines indicate that a fluid aspiration (removal of a small amount of fluid for testing) should have been arranged to rule out infection in the pleural space (cavity between lungs and chest wall). This was not arranged until almost eight weeks later. When this was done and the result was inconclusive, guidelines recommended that a biopsy be carried out and this wasn't done either. In addition, an ultrasound scan the following day reported ascites (fluid within the abdomen), and again a fluid aspiration was indicated but wasn't carried out.

A biopsy via thoracoscopy (keyhole camera into the pleural space) was not carried out until a further 14 weeks later. A's cancer was diagnosed thereafter. We found that there were earlier indications for a thoracoscopy and missed opportunities to diagnose A's cancer from the time of their initial presentation. While we acknowledged that an earlier diagnosis was unlikely to have altered A's prognosis, we noted it would have enabled palliative care to commence and allowed the family time to prepare and make the most of the time they had left together. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out appropriate investigations in a timely manner, and for the consequent delayed diagnosis and impact of this on A and the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Adherence to relevant national guidelines on managing pleural disease and managing ascites. Appropriate investigations carried out as and when indicated, leading to timely diagnosis.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.